Teodor Grantcharov’s idea for transforming one of the riskiest areas of medicine is so provocative, the Toronto doctor figures it could never have been launched in the litigious world of American health care.

Inspired by a crucial element of aircraft-accident investigations, the respected surgeon has developed an “O.R. black box” to help get to the bottom of potentially harmful errors made during operations — errors that are blamed for hundreds of deaths in Canada every year.

The equipment simultaneously records video and audio of what is happening both in the operating room and inside the patient’s body, generating a detailed electronic log of the treatment, mistakes and all.

The idea is not to aid personal-injury lawyers, but to encourage better work and identify when and why problems occur, so they can be prevented in future.

This has the potential to change the way we practise surgery

The system is being tested now at Toronto’s St. Michael’s Hospital, but Dr. Grantcharov envisions the day the equipment becomes a standard feature of operating rooms around the world.

“I believe this has the potential to change the way we practise surgery,” he said.

“I’m sure some people will feel threatened, like pilots felt threatened when the black box was first introduced,” said the physician. “But … we are a high-risk, high performance industry and all of us can be patients one day, and we would like to make sure everybody performs to the standard.”

Dr. Grantcharov, a towering, genial native of Bulgaria who came to Canada via Denmark and the U.S., is presenting preliminary results from his pilot study of the black box at the prestigious American College of Surgeons conference in Washington, D.C., next month.

Already, it has garnered international attention. The Hvidovre Hospital in Copenhagen is about to begin its own study using the system, and might install it widely if the results are positive, said Dr. Svend Schulze, chief of surgery at the facility.

THE CANADIAN PRESS/Nathan Denette

“I think it will improve the outcomes, and find pitfalls before accidents happen,” he said.

Dr. Garth Warnock, president of the Canadian Association of General Surgeons, said it seems like an excellent idea, so long as it is used for education, not to “shame and blame.”

“In my institution, I would be the first to offer up my operating room,” said the Vancouver-based surgeon.

As one of Dr. Grantcharov’s patients, Nicole Muzzo was equally enthused.

I think it will improve the outcomes

When the surgeon removed her entire stomach to treat an advanced cancer, the black box recorded everything. The surgery was a success, but she felt added confidence knowing that a virtual record was kept.

“I’m asleep, I don’t know what’s happening,” said Ms. Muzzo, 64, an interior designer and retired teacher. “Hopefully I’m going to wake up and everything will go as it should. [But] sometimes things go wrong, and this would be a way of going back and finding out what went wrong.”

The impetus for the project is not difficult to pinpoint. Just as operations can improve or even save patients’ lives, they carry considerable risks. The landmark, 2004 “Baker-Norton” study on medical error estimated that 9,200 to 23,000 Canadians die annually because of preventable “adverse events” in hospitals. The largest single source of mistakes identified by the researchers was surgery — accounting for 34% of the total.

Dr. Grantcharov said the black-box concept emerged as well from his longtime interest in aviation, an interest so keen that he actually reads accident-investigation reports posted online by regulators.

What struck him is that, no matter how inexplicable an airline crash may have seemed at the time it happened, investigators almost always deduce the chain of events that led to catastrophe — and then issue recommendations on how to prevent similar mishaps.

The black boxes introduced on airplanes in the 1960s — which are actually bright orange and record both the voices in the cockpit and data sent over the plane’s electronic systems — play an invaluable role in reconstructing what went wrong.

“The pilots now will be familiar with what happened — everybody knows how to prevent this,” he noted. “[But] if there is an event in the operating theatre, or an adverse outcome, nobody really deals with it.”

I’m asleep, I don’t know what’s happening

Health care causes many more deaths than flying and yet “still there is less transparency,” added Esther Bonrath, a German surgeon and University of Toronto PhD student who is analyzing the operation recordings.

This is not the first time in the last several years that health care has borrowed from aviation, as it focuses unprecedented attention on patient safety. A pilot-like checklist has been implemented in operating rooms worldwide after an international study suggested it could significantly reduce complications.

The OR black-box system is so far being applied to minimally invasive surgery — Dr. Grantcharov’s specialty — but he says it could be applied to conventional, open procedures, too.

The equipment records the inside-the-belly view from the surgery camera, which produces the TV image that guides the surgeon during the operation, as well as the view from a ceiling-mounted camera that shows the entire OR. Conversation in the room is also captured.

Although he is the only surgeon whose work has been recorded so far, anesthetists, nurses and other OR staff had to be briefed and give their consent before the camera could be turned on. The reception has been generally positive, said the surgeon.

Tom Blackwell/National Post

The results can be viewed all on one computer screen, the two video images side-by-side, overlayed by the soundtrack.

Three team members have been analyzing the operations for technical errors — slip-ups by the surgeon in manipulating the instruments — and non-technical mistakes — breakdowns in communication, leadership or decision-making among the OR team.

Dr. Grantcharov said he can’t divulge details of the group’s findings until after the conference presentations, but revealed they have detected errors he never knew were happening.

They include inadvertently pushing the needle out of view of the surgery camera, with the risk of the unseen instrument poking a hole in the bowel, an injury that then must be stitched up — if it is caught.

“I wasn’t paying attention to this before,” he said. “Now, every time I get the needle out of my view, I correct it very quickly … It changed the way I practise.”

Near misses are not registered and not talked about

Though surgical mistakes can include true horror stories, like removing the wrong kidney or breast, the cause of complications is often more subtle. The errors Dr. Bonrath has catalogued have all been relatively minor deviations but “many, many small things lead to one major thing,” she said.

Focusing on what is happening in the wider operating room, Nick Dedy, an orthopedic surgeon and doctoral student who is also from Germany, said he has noticed problems with communication between OR “sub-teams.” Surgeon, anesthesiology team and nursing team sometimes “work for themselves,” when they should be interacting better across disciplines, he said.

One advantage of the system is that it documents the “near misses” — mistakes that do not affect the patient’s outcome but could deliver important lessons on how to prevent harm in future.

“Right now, in a lot of hospitals in the world, near misses are not registered and not talked about,” said Dr. Dedy. “People are maybe afraid to experience some disadvantages in their career if they speak about it.”

If the system is one day widely embedded in hospitals, time-consuming analysis would likely take place only after patients suffered serious complications, or as part of a random quality-control process, said Dr. Grantcharov.

Still, simply knowing that their work is being recorded would have a significant impact on health-care professionals, he and his team argue.

“One of the keys of this whole initiative is going to be introducing a culture change in the operating room,” said Dr. Dedy. “The main goal is not to look good on camera or make a good impression or not be sued, it’s safety.”

When health workers are more transparent, of course, they can also end up more vulnerable to legal and regulatory scrutiny. Dr. Grantcharov emphasizes repeatedly that the goal of his project is educational — to learn from and prevent mistakes, not to assign blame — but concedes the black box could be used for other purposes.

“It’s a free country, if people feel something was done inappropriately, they have the right to take action,” he said. “If they take action now, we report to the best of our ability. We document everything, we report everything. Theoretically, [with the black box] it shouldn’t be different.”

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